One smart upstream investment

It’s hard enough for most of us to make smart long-term plans. It’s really hard for politicians to do it. So a year ago, at the beginning of our Agenda2020 series on the deep future of American health, we pulled a group of experts into a room in Washington and asked them: If we want to improve the health of a changing nation, what would you do?

Overwhelmingly, they converged on one big message: Health isn’t just about health. Real improvements in the national health – the kind that increase our average lifespan, boost our prosperity, and maybe even bend the curve of escalating costs – depend on connecting a whole network of services and life influences. They also take decades, meaning that if we want a healthier America not just in 2020, but in 2040 or 2050, we need to make some big decisions now.

So what should we be focusing on? To wrap up our yearlong series, we returned to our panel of experts, as well as a number of others who have contributed to our series over the past 12 issues, for one big idea. If Washington could invest in one “upstream” factor – one big commitment to shape the future of national health – what should it be? Their answers ran the gamut, from a bold new attack on child poverty to a better vision for elder care to a “foresight fund” that would prioritize the kind of investments politicians have trouble making.

Cut child poverty in half

Mona Hanna-Attisha is a pediatrician at Hurley Children’s Hospital and associate professor at Michigan State University College of Human Medicine in Flint, Mich. She is the author of the forthcoming book, What the Eyes Don’t See.

Six out of every 10 kids, and often more, come to my clinic in Flint with an ailment far more dangerous than anything an X-ray will diagnose or an antibiotic will cure: They’re poor. As pediatricians, we know poverty is one of the strongest risk factors for bad health, increasing rates of asthma, obesity, slow language development, infant mortality and injuries. These aren’t just abstract risks, as we discovered at our clinic: being poor in a poor city literally poisoned our children with dangerous levels of toxic lead.

In Flint, the child poverty rate is almost 60 percent. And Flint kids are not alone. Nationally, the child poverty rate is about 20 percent. According to the Stanford Center on Poverty and Inequality, the United States has become “a clear and constant outlier in the child poverty league.” The more we learn about poverty and the developing brain, the more we realize how poverty — especially early, deep and persistent poverty — can distort the brain and dramatically alter a child’s entire life trajectory. Add this new scientific knowledge to the reality of increased economic inequality and the difficulty of poor people to break out of the economic trajectory they are born, and the American promise itself is at risk.

In the next 10 years, we should aim to cut child poverty in half. The U.S. has had successes in poverty mitigation before. We effectively eliminated senior poverty with the creation of Social Security and Medicare. We’ve even cut the rate of child poverty in half since the 1960s. Now we need to do it again. There are so many evidence-based and cost-effective strategies that work: increasing the minimum wage, developing robust prenatal and parenting support programs, giving kids access to nutritious food in schools and at home. We also need to provide universal high quality child care and preschool for all kids from birth through age 5, and improve the K-12 education system in our poorest communities. But that is not enough. The easiest and boldest way to reduce child poverty is to provide supplemental income support to families with children, similar to the family allowances provided in many other countries. This benefit should be for every child. No matter where they were born, in this country or elsewhere, or how much their parents make. It is time for our policies to catch up with the burgeoning science of child development promotion and poverty mitigation. It is time for our policies to prioritize children.

Build a real long-term care system

Bruce Leff is a professor of medicine and director of the Center for Transformative Geriatric Research at Johns Hopkins University School of Medicine. His Agenda2020 video on providing more health care in patients’ homes can be seen here.

As the population ages, and medicine extends our lives, more and more Americans are finding themselves needing long-term care outside the hospital — and discovering that they’re largely on their own. For all the success of Medicare and Social Security in building a safety net for old age, the U.S. lacks any sort of coherent policy or insurance system for long-term care. Most people live under the impression that Medicare will pay for the services and supports they need — only to discover that it does not. In fact, Medicaid is the default long-term care payor, but kicks in only after people spend down their assets, effectively forcing people to impoverish themselves before they get any support. Only people in the wealthiest 10 to 20 percent of older adult households have enough savings to absorb the risks of high long-term care spending. Few people purchase long-term care insurance policies, often for good reason. (I recently investigated buying a policy for myself and decided to take a pass — they were quite expensive, didn’t deliver much in the way of benefits, and it wasn’t clear that the insurance companies would still be in business when I eventually might need them to pay a claim.)

A critical upstream decision we can make now is to develop and implement a long-term care safety net, a combination of insurance, social support and related policies. Other countries have done this. Pursuit of long-term care insurance policies won’t be an easy sell at a time when entitlement programs appear to be on the chopping block — but if we don’t, we risk massive economic and social disruptions as the silver tsunami crashes on our shores in the coming decades.

Develop tools for people to manage their own health

Alan Morgan is CEO of the National Rural Health Association. His video for Agenda2020 on the challenges of promoting health in rural America can be seen here.

Americans need better tools to manage their own health. Rural Americans know this already because we have less access to health care providers. New technologies are already starting to empower people to take control of their own health, and we need more — new tools so people can easily and affordably track their own diet, sleep, stress, exercise and overall well-being. As much as 40 percent of a person’s overall health status is determined by behavior alone, so investing in people's power to change their behavior is the key to improving our nation’s health status, addressing rural health disparities and significantly reducing costs.

Close the education gap

Joshua Sharfstein is a professor of public health at the Johns Hopkins University School of Public Health and former secretary of the Maryland Department of Health and Mental Hygiene.

Of all the inequities in American life, profound gaps in educational opportunities cast the longest shadow. School failure leads to a myriad of health problems, from substance use and teen pregnancy to chronic illness and premature death. And it is a tragedy that plays out in slow motion: Chronic absenteeism in early grade school predicts late reading, which in turn is associated with school troubles and eventual dropout.

A new commitment to educational equity that tackles the segregation of profoundly poor children in substandard schools will pay dividends in health for decades to come. In addition to such strategies as providing additional resources, promoting integration and increasing support for innovation, it will help to mobilize other sectors to support school success.

One of those sectors is the health care sector itself. Doctors and hospitals can help by aligning their metrics — and rewards — with school success. For example, insurers can provide bonuses to clinicians when populations of students achieve better school attendance, grade-level reading and other indicators of achievements. A key tool is sharing data. With consent from parents, schools can send information on attendance and achievement to clinicians in order to guide management of chronic illnesses such as asthma, identify early warning signs of learning disabilities and recognize hidden social needs.

A convergence of health and education is not as far-fetched as it may seem. Cincinnati Children’s Hospital has adopted improved third-grade reading in the public school system as a strategic goal, and is involved in providing books, training teachers in quality improvement, and making other supportive investments. Johns Hopkins Universityis working with the Baltimore City Health Department and the nonprofit Vision to Learn to ensure access to eyeglasses to all city schoolchildren. With the right incentives, projects targeting absenteeism and dropouts, and other core measures of educational success, might not be far behind.

Look beyond our borders

Prabhjot Singh is director of the Arnhold Institute for Global Health and chairman of the Department of Health System Design and Global Health at Mount Sinai Health System. His essay for Agenda 2020 on the connection between housing and health can be seen here.

When it comes to solving America's toughest and most complex health challenges, we cannot only look to our own experience. We need to shift our mind-set and search globally, looking to other countries and societies for locally driven, practical solutions that have endured and spread. Americans are rightly proud of their record of health innovation, but resourceful people in poor, challenging settings have their own remarkable record. For example, we “discovered” community health centers in South Africa, and over the past 40 years, they have spread nationwide in a uniquely American form. What if we looked to Liberia’s powerful community-based Ebola response for clues to fighting the opioid epidemic? What if rapidly aging American communities worked alongside Japanese communities to make sure that no elderly person was lonely? What if our most distressed communities redesigned their public spaces with new friends in Copenhagen? What if America genuinely opens up to the possibility of learning from everywhere? If we do, I believe we can be the healthiest nation within a generation.

Take child care to the next level

Esther Dyson is a technology investor, futurist and executive founder of Way to Wellville, a 10-year project to help five communities keep their members healthy. One of its communities, Muskegon County, Mich., was featured in an Agenda2020 article on obesity.

Resilient children with a strong sense of security are less vulnerable to a whole host of behavior patterns that damage their health as they grow up, from addiction to poor eating to drugs to porn—really, anything driven by short-term gratification rather than long-term purpose. It's easy to identify this opportunity but hard to take advantage of it, because children’s behavior is so dependent on their parents, whose behavior patterns are in turn dependent on their parents’ patterns years ago. To break that cycle, we as a society need to implement broad, high-quality pre- and post-natal care and training for parents who need it—and to pay for that preschool care work with wages that reflect its long-term value. At a time when there’s broad concern about long-term lack of jobs for many Americans, pouring substantial resources into training the trainers for caregiving jobs for children would be an excellent and high-return use of our resources. It will not just improve the mental and physical health of future generations, and reduce health care costs; it will also make society more prosperous overall by raising productivity, and thus tax revenue. Reducing addiction, crime, poverty and other social ills will have its own beneficial effects, in turn improving the resilience and sense of security for the next generation of children. We just need to start that virtuous cycle.

Change our expectations

Jane L. Delgado is president and CEO of the National Alliance for Hispanic Health.

The key to improving public health is to reframe what we think, fund, and do in America. We often operate on certain assumptions about people and economics that really don't pertain to the health sector, and we'll be far more successful if we can accept three major facts and the implications of each one. First, prevention does not save money. In fact, early death is the biggest health system cost savings. We should invest in prevention because we are a civil society and want each person to be as healthy as possible, not because we're trying to save money. Second, one size does not fit all or most. Our health systems must be attuned to the genetics, culture and microbiome of the individual. Personalized medicine is the future. And third, all communities want to have clean water to drink, clean air to breathe, safe food to eat, safe products to use, and safe places to live, work and play. We often respond to the loudest, or best-connected, but we need to support all individuals in the hard work that they do to lead a healthier life, and fund programs and support policies that are tailored to the needs of individuals and communities. And we should do it because health matters — because it's the right thing to do — and not just as a way to save money.

Make childbirth safe

Neel Shah is assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School, and director of the Delivery Decisions Initiative at Harvard’s Ariadne Labs. His essay for Agenda2020 on the evils of hospitals beds can be read here.

It is hard to imagine a health care service that has more value to society than childbirth: Nearly every American experiences it. But if you were tracking the health of our nation’s mothers, you'd never know it mattered to us. During the bleary-eyed, universally challenging weeks after giving birth, most American women have minimal contact with their health care provider and face unrelenting pressure to return to work. Meanwhile, the number of American women who experience depression, hypertension and other potentially life-threatening complications during this period has been rising for decades. In 2017, women in the United States are more than twice as likely to die within six weeks of giving birth than women in any other developed country.

The investment in childbirth and early maternal care could be widely shared. Rather than losing touch with most mothers during those critically important weeks after they leave the hospital, our health care system could ensure that they are adequately supported when they return home — particularly for those who are most vulnerable. Employers could invest in paid family leave policies that are on par with the rest of the developed world. Facility planners who could ensure public spaces have adequate nursing facilities. Every member of society has a role to play in improving the well-being of our moms.

Rebuild the elder-care system

Joanne Lynn is director of the Center for Elder Care and Advanced Illness at Altarum, a health care research and consulting firm. Her Agenda2020 video on the coming crisis in elder care appears here.

Growing old is a tremendous boon, and so many of us boomers will be growing old together that the population will be visibly older than it has ever been. We should celebrate that most of us will have more than 80 years in generally good health! But our social arrangements are terribly unprepared for that future. On a national level, we have no real plan for available and affordable disability-adapted housing; we have no real plan for a suitably skilled workforce in sufficient numbers to care for the aging. Indeed, we don’t even have a plan for adequate retirement income, the kind of safety net that can support the full length of modern old age. We need a focused period of guided innovation now, enabling lots of local communities to figure out how to ensure that each of us, growing old, can count on living as meaningfully as possible. We need a financing strategy for elder care that benefits the economy, rather than being a looming threat to family, community and state resources. We need to develop new financing and service delivery arrangements that focus more on reliable supportive care and less on conventional medical treatments. If you look around at American communities and organizations that have started to grapple with these challenges, you can see that we have the start of workable models, but we need the political will to test and learn and develop them on the far larger scale that America will soon require.

Long-term health insurance contracts

Avik Roy is co-founder of the Foundation for Research on Equal Opportunity, a nonprofit think tank based in Austin, Texas.

Nearly every American with private health insurance enrolls in plans that last one year. If you’ve enrolled in coverage on Obamacare’s exchanges, you have the opportunity to switch insurers each year. If you get insurance from your employer, your employer has the opportunity to switch coverage each year. And the same opportunity exists for those in private Medicare plans. But we never stop to ask: Why only one year?

This one-year system is a huge problem when you consider how our health care incentives really work. Under one-year contracts, insurers have less incentive to invest in preventive health because the rewards from prevention are likely to manifest themselves several years later -- when their enrollees might be in another plan. Here, we can borrow an idea from Switzerland: five-year insurance contracts. Swiss insurers offer these longer-term health plans at a significant discount, especially if enrollees meet certain targets for prevention, like low cholesterol levels or normal blood pressure. Simple policy reforms could make such plans far more widespread in America than they are today.

Generate better local data

Lanhee J. Chen is the David and Diane Steffy Research Fellow at the Hoover Institution and director of domestic policy studies and lecturer in the public policy program at Stanford University.

America is a nation of constant innovation, much of it local, and the policies that will have the greatest impact on the future health of the American people will come not from Washington, but from our cities, counties and states. So the future health of our nation depends on a better understanding of how policy changes at the local level can improve people’s livelihoods. To better target interventions to help people live healthier lives, we need to develop broader and more comprehensive measures of not just health factors, but those factors influencing health, at the local level.

Examining trends at the local level can teach us a lot about where policy changes are needed. For example, the Robert Wood Johnson Foundation has worked with the University of Wisconsin to compare counties across the country on 30 “health-influencing” factors, ranging from whether people drive alone to work to a measure of income inequality. These metrics can help local policymakers see, for example, the degree to which the growing opioid epidemic is leading to premature death among working-age Americans; the relationship between the lack of housing and poor health; and the degree to which air pollution and other environmental factors impact quality of life. All of these problems will be solvable in the future, but will require strong action from local and state policymakers. What we need is better and more data to help guide them in their efforts.

Break down structural racism

Tyson Brown is an assistant professor of sociology and director of the Center for Biobehavioral Health Disparities Research at Duke University. His video for Agenda 2020 on how racial and economic disparities affect health can be seen here.

The most important decision we can make today to improve population health tomorrow is to address structural racism and its harmful health consequences. Structural racism—i.e., the systematic exclusion of some people from resources and opportunities on the basis of their race—limits access to health-promoting resources for racial minorities, such as good schools and jobs, healthy communities and quality health care. It also increases their exposure to factors that are harmful to health, such as chronic stressors, discrimination and incarceration. These processes generate dramatic racial inequalities in heath in the U.S. and result in unnecessary suffering, premature mortality and excess economic costs of over $300 billion annually.

Reducing structural racism and racial health disparities will require bold actions, but these actions can take the form of cost-effective, race-neutral policies that would improve overall population health. For example, policy initiatives such as the Child Trust Account Program, Federal Jobs Guarantee, Criminal Justice Reform, and the enforcement of the Fair Housing Act would reverse the rising tides of economic and social inequality that are undermining our nation’s health. These policies would disproportionately benefit communities of color and go a long way toward achieving health equity, while at the same time improving the health of the U.S. population as a whole.

Build a post-carbon economy

Howard Frumkin is professor of environmental and occupational health sciences at the University of Washington School of Public Health. His article for Agenda 2020 on the new science of planetary health can be seen here.

Climate change threatens health on a vast scale, from heat waves to disasters, from cardiorespiratory diseases to infections. All trends point to worsening of these risks in coming years unless we change course. To provide a stable basis for human health, we need to move rapidly and aggressively toward a post-carbon, sustainable economy. Climate and energy policies are health policies; these should include elimination of all fossil fuel subsidies; rapid phaseout of fossil fuel production on federal lands; promotion of clean renewable energy; promotion of clean, healthy transportation; promotion of land use and agricultural practices that reduce greenhouse emissions and sequester carbon; urban policies that encourage walking and cycling, vibrant neighborhood centers, mixed land use, and density balanced with green space; and promotion of green, efficient buildings. These will yield both immediate and long-term health benefits: reduced asthma from reduced air pollution; improved cardiovascular health from more physical activity; limiting the spread of infectious diseases such as Lyme disease and dengue fever; fewer deaths from motor vehicle crashes; and more.

Launch a Foresight Fund

Anthony So is a professor at Johns Hopkins University’s School of Public Health and founding director of the university’s Innovation+Design Enabling Access Initiative. His video for Agenda2020 on the threat of antibiotic resistance can be seen here.

One of the most important upstream decisions we might make is to develop a Foresight Fund, a foundation that could make evidence-based investments into longer-term, public health priorities that are hard for governments to address. From Ebola vaccine to tobacco control, policymakers too often fail to pay now to avert paying more later. Though antimicrobial resistance, if unchecked, may impose an economic toll of up to $100 trillion dollars by 2050, governments have invested little to avert these future costs. With the Foresight Fund, we could move beyond making small, near-term bets—company by company and drug by drug—to investments that transform the innovation ecosystem. We could design innovative financing mechanisms that require upfront capital to implement antimicrobial stewardship in our health care delivery and food production systems. Prevention gains and intergenerational costs are seldom as compelling as today’s crisis, but we can correct this. The Foresight Fund could be seeded with a solidarity contribution, like UNITAID receives from participating countries on airline tickets, but this could be levied on international financial transactions. Over time, a coalition of the willing — both of countries and foundations — might make contributions to such a multilateral fund. Independent of these funding sources, however, the Foresight Fund could establish a framework for investing in these future public health risks, and in so doing, the process of prioritizing these issues will itself return dividends by informing policymakers of the challenges ahead.